The connection between the local availability of tobacco products and smoking behaviour has been underlined in new research from the CRESH team this week. Published in the journal Tobacco Control, we show how moving into an area of Scotland where tobacco products are more readily available can significantly increase the risk of smoking while pregnant. We estimate that a pregnant woman living in an area with the highest tobacco availability is 70% more likely to smoke than when she was living in an area with the lowest availability of tobacco products.

Why is this important? Firstly, smoking during pregnancy is a vital Public Health issue and is recognised as a key priority area for UK health policy. It is harmful for both the mother and the developing fetus and the effects for social and health outcomes can persist into childhood and adulthood. Since smoking is so strongly associated with poverty and deprivation, it also has an important role to play in the persistence of health inequalities across generations.

But there are other reasons why the research is important. Much of what we know, including previous research from CRESH, is based on information from a single point in time. While these studies are crucial in establishing the strength of associations, they are less useful for determining mechanisms. A key question that remains is whether high availability is the cause of smoking behaviour or whether retailers preferentially locate in areas of high demand. Both pathways are plausible but both carry very different conclusions and policy recommendations. Our latest research is able to address this question using information on smoking during pregnancy which is collected routinely as part of Scotland’s hospital maternity records. By looking at multiple pregnancies to the same individual, we were able to relate changes in smoking behaviour between pregnancies to changes in exposure to tobacco retailers from residential moves. This approach provides strong evidence that availability is causally linked to behaviour.

The policy implications are clear. As more and more countries move towards a “Tobacco Endgame” policy this, and other research, highlights how a focus on tackling the local availability of tobacco products will be crucial. In a week where the UK government has suggested that preventing poor health lies with “people choosing to look after themselves better, staying active and stopping smoking” our findings are a timely reminder of the importance of considering the wider set of structural factors that shape our health of which our residential environment is one important component.

Applications are invited for an Early Stage Researcher position funded by the Marie Sklodowska-Curie Innovative Training Network “LONGPOP (Methodologies and Data mining techniques for the analysis of Big Data based on Longitudinal Population and Epidemiological Registers)” within the Horizon 2020 Programme of the European Commission. LONGPOP is a consortium of universities, research institutions and companies located in Spain, Netherlands, Sweden, Italy, United Kingdom, Belgium and Switzerland, The successful applicant will join a network of 14 Early Stage Researchers who are already embedded in the consortium. This is a high-profile position that offers exceptional benefits ideally suited for top graduates.

This position is based in the Centre for Research on Environment Society & Health and Longitudinal Studies Centre Scotland, School of GeoSciences at the University of Edinburgh. You will join a broad, dynamic research team with interests in population health, demography and human geography. You will be expected to work with other investigators of the network, both in Edinburgh and at the other LONGPOP network institutions.

The post is available as soon as possible and is fixed term until 31st January 2020.

The important influence of the places in which we live, work and play on our mental health and wellbeing was the topic of a recent lively discussion at the Edinburgh Science Festival 2017 organized through Centre for Research on Environment, Society and Health (CRESH).

The event was chaired by Professor Jamie Pearce, (from School of GeoSciences at the University of Edinburgh and CRESH) and, in his introduction, he emphasised the policy-relevance of the event as evidenced by the Scottish Government’s newly released Mental Health Strategy 2017-2027. The Strategy details how institutions, services and organisations will work together to enhance mental health in Scotland. Especially relevant for this discussion was the acknowledgement on P8 of the report that ‘Working to improve mental health care is not just the preserve of the NHS or the health portfolio. We will be working not only across the Scottish Government, but also across the wider public services to harness the broadest range of opportunities to improve the population’s mental health…’. It is therefore acknowledged that promoting good mental health and wellbeing is not only about medical care, but also involves action to improve the ‘wider determinants’ of mental health – especially how conditions in the places where we live, work, learn and play can affect mental health and wellbeing.

We were therefore interested to explore how academic research contributes to our understanding of how places affect wellbeing. Our main aim was to exchange ideas with our audience of over 70 people, representing a range of views from those living in the communities in and around Edinburgh. Several participants also reported on knowledge and experience gained in their professional lives, including medical practitioners, public health specialists, leaders in independent organisations whose mission relates to mental health and wellbeing (such as Support in Mind, and the Cyrenians), urban planners and architects and social service providers.

The event started with a series of comments from a panel of academic researchers representing a variety of social science disciplines, who introduced ideas from academic research that may help to frame thinking on these issues.

Professor Sarah Curtis (Professor Emeritus at Durham University) used her own experience of volunteering in the Edible Garden project at the Botanic Gardens to illustrate ideas from Health Geography about Therapeutic Landscapes, originally put forward by Wil Gesler (e.g. in his book on Healing Places). This conceptual framework suggests we can think of places in terms of: material and physical landscapes (agreeable and relaxing green spaces, water spaces and built environments), social landscapes (supportive social relationships and community processes) and symbolic landscapes (features of our environment that stand for beliefs, principles and memories that are important for us). All of these dimensions of places, experienced in the different settings where we spend our lives, can be important for creating and maintaining our sense of mental wellbeing. These features of landscapes, the ways they change, and how different groups of people experience them over time, have been studied extensively by health geographers (e.g. reviewed by Sarah Curtis in her book Space, Place and Mental Health).

Professor Steve Platt (Professor Emeritus at University of Edinburgh) then presented ideas from research in Sociology and Health Policy about what we might consider the ‘reverse’ of therapeutic landscapes; focussing on factors that are associated with risk of suicide and why suicide matters for suicide prevention. He used the example of the iconic Golden Gate Bridge in San Francisco, which has been a ‘magnet’ for people intent on taking their own lives. He described the public controversies surrounding action to alter the architectural form of the bridge in order to install protective structures to reduce the suicide risk. He also underlined the evidence for socio-economic deprivation as a risk factor for suicide, with the risk of suicide being 2-3 times higher in the local areas in Scotland ranked among the worst 10% for social deprivation, as compared with populations living in areas ranked in the least deprived areas. He went on to elaborate further on the idea of suicidogenic contexts combining various dimensions that may be cultural, socio-economic, political, historical, as well as including built infrastructures and other aspects of the physical environment.

The significance for wellbeing of green space, viewed from a Landscape Architecture perspective, was introduced by Professor Catharine Ward Thompson, Director of the OPENspace Centre at the University of Edinburgh’s College of Art. She underlined that, since stress is a major problem for society and is associated with physiological as well as mental illness, researchers at OPENspace, together with their colleagues from around the world, are exploring how attractive and accessible green spaces can have beneficial ‘restorative’ effects on our mental state and help us to cope better with stress. Studies using biomarkers (that measure the functioning of psychoneuroendochrine systems in the human body) show that our mental and physical states are linked, which helps to explain why environments that help to restore mental wellbeing are also helpful for our physical health. Good access to green and natural spaces in the residential environment is associated with lower levels of stress as shown by these biomarkers, as well as from self-reports of stress among people out of work and living in urban poverty. Attractive green spaces are often also places where we enjoy supportive social relationships and healthy physical exercise. Conversely, when there is a shortage of green space in the urban environment, this appears to be associated with feelings of loneliness and lack of social support. Professor Ward Thompson has published research exploring these relationships in the journal Landscape and Urban Planning and the International Journal of Environmental Research and Public Health. Findings such as these help to strengthen the case for providing and maintaining access to healthy green spaces, such as public parks and gardens, allotments, and public rights of way in the countryside.

Dr Niamh Shortt (School of GeoSciences at the University of Edinburgh) leads research at CRESH relating to how aspects of consumption and retail environments are significant for behaviours linked to mental health and wellbeing. She focused her talk especially on issues associated with alcohol consumption and unhealthy drinking, which can be closely linked to mental distress and mental health conditions. While lower income groups report consuming the same, or less, alcohol on average than higher income groups, they suffer more from alcohol related harm. This has been called the ‘Alcohol Harm Paradox’. Dr Shortt presented findings from research she is leading which show that risks of unhealthy alcohol use are not only associated with individual level characteristics, but can also be influenced by the social and commercial environment. Access to and advertising of retail outlets selling alcohol is not currently controlled to the same extent as for tobacco sales, yet research is showing that there the ways people drink may be influenced by the organization and availability of alcohol retailing in their neighbourhood, and that this is especially important for those living in poorer areas who may be most reliant on their local retail facilities. This research demonstrates the importance for wellbeing of work of retail planning and licensing systems.

As the discussion widened to include the audience at this event, a number of other thoughtful and important points were made. We heard from a number of representatives of relevant non-academic organizations, explaining how actions to promote mental wellbeing and to prevent and treat mental illness may draw upon research, and also contributes to knowledge about ‘what works’ to promote wellbeing.

Dr Margaret Douglas, Consultant in Public Health Medicine for NHS Lothian, underlined concerns about the unequal impacts of places on both health for different groups in Scottish society. She highlighted links between physical and mental health. The geographical variations in mental health and wellbeing, and inequalities between rich and poor areas, are a major issue for public health in Scotland, as in other countries, so research is important to help to identify the places where health disadvantage is most concentrated and needs for mental health care are greatest. This said, not all of the people most at risk of poor mental wellbeing and mental illness live in the poorest areas, so that there is also a need for information on the social and geographical pattern of mental health problems across the whole of Scotland. Dr Douglas particularly noted the range of aspects of the environment that are important for health. Her comments drew attention to the range of partners who need to collaborate to address actions to improve the various environmental factors that are beneficial for wellbeing and can help to prevent mental health problems. The Scottish Health and Inequalities Impact Assessment Network has produced documents summarising evidence on several aspects of the environment including community venues, greenspace, transport and housing.

These comments were reinforced by Johnny Cadell, from Architecture and Design Scotland, who underlined the significance of Scottish Government architecture policy (Creating Places), Scottish Planning Policy and the Place Standard, which promote healthy environments across Scotland. The Place Standard is a joint initiative between Scottish Government, Health Scotland and Architecture & Design Scotland. The discussion highlighted the strong interest in how good urban design can benefit mental health. We noted that there is very good potential for the transfer of knowledge from research into policy and practice, and this is gaining momentum through collaboration between researchers and government agencies promoting various initiatives, such as work by the Design Council entitled ‘Active by Design’ and, in Scotland, initiatives such as ‘Good Places Better Health’, ‘Go Well in Glasgow’ and, most recently, the development of the ‘Place Standard Tool’ to guide local development. Increasingly, Health Impact Assessment is being applied to interventions outside the medical sector, to ensure that health impacts of new urban developments are considered at the planning stage. The Place Standard brings together commitments in architecture policy (Creating Places) to produce a tool linking spatial design with the health/wellbeing agenda and the commitment in Good Places Better Health to produce a ‘Neighbourhood Quality Standard’. Those involved in Good Places Better Health and Go Well were closely involved in the design of the new tool.

Frances Simpson, from Support in Mind, helpfully drew attention to the fact that a good deal of research is currently focussed on more urban communities, but that it is also important to understand the experience of the rural communities in Scotland. Among a range of activities promoted by Support in Mind is a project that is currently collecting valuable information on what it is like living with mental ill-health in rural Scotland. Communities in rural areas may benefit from greater proximity to extensive green spaces than those living in cities, but there are other issues such as social isolation and exclusion, and problems of access to the right kinds of mental health services, which need to be considered in rural settings. These points resonate with an article recently published by Hester Parr and Chris Philo in The Geographer magazine reporting research involving participants in rural areas.

Hugo Whitaker, from the charitable organization Cyrenians, also pointed out that recovering from mental illness can be a long process and that access to supportive environments over time can be very helpful to restoring mental wellbeing. He provided examples (including 2 film clips) of how community gardens and healthy activities organised in grounds that are part of NHS estates can help to restore and maintain good health.

A number of useful film clips have also been published by the Green Exercise Partnership to help spread the word about this kind of activity (see example film here), as well as recordings of individual accounts from the perspective of those involved in design and planning (here) and stories of patient users’ experiences: (here).

Also relevant to this debate is the Our Natural Health Service action programme. It shows how “high quality local greenspace, supportive nature-based projects, and better links between health and social care practitioners and the environment sector, can be part of the solution to many of Scotland’s health issues.” NHS Lothians’s report‘Health Promoting Health Service: Action in Secondary Care Settings’ issued by the Chief Medical Officer in October 2015 includes targets on “current use and improved plans of the outdoor estate for physical activity (green exercise and active travel) for staff, patients and the local community” as well as targets for staff health and wellbeing.

The debate included further comments from a number of other members of the audience. Points made by the panel about long term effects were picked up on by a retired General Practitioner who practised in one of the most deprived areas in Scotland. He commented that deprivation was transmitted across generations and that the conditions causing mental health problems in one generation would resurface in the next generation who were also treated in his surgery. Research reporting on the environmental experiences of people at different life stages was considered. For example, experiences of adolescents were commented on and it was pointed out that mental health problems can become apparent relatively early in life, and that young people have relatively little control over the social and physical environment, so it is important for their voices to be heard in environmental planning processes. Aspects of the environment that are beneficial for wellbeing of young people vary from those which are important for adults, so their experience needs to be taken into consideration.

Individuals with different characteristics may react quite variably a given environment and research can help to improve understanding of how places interacting with personal characteristics relate to mental wellbeing. It was noted, for example, that people vary in terms of cognitive and physical abilities and that making public spaces well adapted and inclusive for people with a range of abilities can help to promote mental wellbeing for all ability groups.

Other comments underlined the importance of a sense of autonomy and freedom to exercise independence and choice in the way we interact with our environment. It was noted that it was not only the visual aspect of the environment that was important, and that it was important for architects and others designing the environment to be sensitive to aspects such as noise levels and ambient temperature which can also affect one’s sense of wellbeing in a particular setting.

Overall, this event clearly demonstrated the breadth of interest in the question of why places matter for mental health and wellbeing. The panel were very grateful to the audience for engaging in the discussion and making such thoughtful comments and to SciFest for organizing the event. We felt this was a good example of how academic researchers and others with relevant ideas and experiences can join together to ‘co-produce’ our understanding of the research agenda and how research can help to inform action. We hope to be able to keep in touch with participants, via the CRESH webpages and blog, in order to share future research findings and knowledge of what is important for our wellbeing in the places where we live.

We are looking to recruit two fully funded PhD opportunities in the area of environments and health. The studentships are funded as part of the UK Farr Institute for Health Informatics Research and both projects will be working at the forefront of health informatics and administrative data research in the UK working closely with colleagues in the Administrative Data Research Centre and the Farr Institute as well as research groups in the School of Geosciences including the Centre for Research on Environment Society and Health (CRESH) and the Population, Health and Place research group.

The successful candidate will have an undergraduate degree (at least 2:1) with a data analytical component from a discipline such as geography, medicine, public health, epidemiology, medical sociology. Experience of statistical data analytical techniques relevant to large-scale and complex social science or health datasets and relevant software packages (Stata, SPSS, SAS or R) is desirable. The precise design of both programmes of research will be developed jointly by the student and the project supervisors and progress towards completion of the PhD will be reviewed in accordance with established guidelines within the School of Geosciences. There is an expectation that the PhD students will contribute substantial independent thinking with regard to the research design, research questions, methodology and analysis throughout the studentship, including preparing and writing results into academic publications where relevant and will contribute actively within the wider research team.

The links below contain more details about both projects including application deadlines, contact details for informal enquiries and how to apply:

While there are many things we can do as individuals to improve our health and wellbeing, action to create a healthier environment also requires community, societal and political responses. We will report on research that explores how and why the places where we live, work and play affect our mental health, and, with the help of the audience, identify some likely ways to make our environment healthier.

People might expect that being in pleasant surroundings can lift our moods, but please can you briefly outline how your research goes beyond this?

We know from lots of research over many years that the places in which we live, work and play can be both beneficial and detrimental to our health and mental wellbeing. Our research has shown that ‘therapeutic’ properties of places include high levels of community cohesion, availability and accessibility of high quality green spaces, and investment in infrastructure to support physical activity, such as cycle paths.

On the other hand, places can be damaging to our mental health if, for example, they are characterised by high levels of crime, pollution, poor physical conditions and a lack of secure and rewarding employment opportunities. Our research also explores how different groups vary in their response to their environment. For instance, the mental health benefits of living in a greener environment are greater for those who are relatively poor, as compared with for wealthier groups. This finding is important, since the Scottish Government and other policymakers need to know what works in terms of environmental planning to reduce health inequalities.

Why is now a good time to highlight the findings of your work?

Like many other countries, mental health in Scotland is a major public health challenge. We know that many mental health outcomes are significantly poorer in Scotland than they are in England. It is estimated that around one in three people are affected by mental illness in any one year. People in the most socially disadvantaged communities are disproportionately affected. For example, our work has shown that adults living in the most deprived parts of Scotland are almost three times as likely to have common mental health problems as those in the least deprived areas.

It is no wonder that improving mental health is a priority for the Scottish Government and is one of 55 national indicators chosen to chart the country’s progress towards the achievement of our National Outcomes – wellbeing targets set by the Scottish Government.

Can you give one or two examples of how people might make simple changes to their surroundings to improve their wellbeing?

Our research has shown very clearly that so much to do with our health is outside of our personal control. To make substantial improvements to our health – including mental wellbeing – requires us to think and act collectively. As individuals, we can get involved in helping to make the places we live more supportive for mental health and wellbeing through getting involved in community initiatives, making therapeutic spaces more accessible, and ensuring our workplaces are supportive.

Can you highlight one or two outcomes from your research that have surprised you?

One of the most fascinating findings from our recent research is that the circumstances early in our lives can have lasting lifelong implications. For example, we have found that characteristics of the places we live during our childhood years can affect mental health and cognitive ageing much later in life. These findings change the way in which we think about the relationships between places and health; to date we have probably not appreciated quite how important places are for our health over our whole lives. It also means that changes we make to our environment now to make places better for mental health are likely to benefit the next generation as well as ourselves.

What is your motivation for bringing your research to the Science Festival?

We think that improving mental health is a major challenge for Scotland and other countries in the UK. To make substantial and sustained progress will require some joined-up thinking, which recognises that mental health is influenced by a range of social, political and environmental factors in our communities. Having conversations about these issues, and identifying possible solutions to such important challenges, is an important way of helping to make sure that important research findings are acted on.

We’re organising a session entitled Health and Place Across the Life Course at the Association of American Geographers Annual Meeting in Boston, MA, April 5-9 2016. If you’re interested in contributing a paper then please get in touch. Further details here:

Session title: Health and place across the life course
Session organisers: Niamh K Shortt and Jamie Pearce, Centre for Research on Environment, Society & Health, University of Edinburgh.

Life course research has been instrumental in establishing that social, economic and cultural factors can influence health in later life either through, for example, an accumulation of effects or through critical periods. There has however been little work by health geographers that has considered how factors that are rooted in place accumulate to influence health and wellbeing through the life course. Reasons for this may include the lack of readily available historical environmental data and the challenges that their collection pose. The absence of such research is problematic because it is likely to restrict our understanding of the ways in which places matter for health, including: the accumulative effects of place over the life course; the critical periods in people?s lives when places are particularly pertinent for health and wellbeing; and, for quantitative work, identifying causal relationships.

This session calls for research papers that incorporate environmental and/or social life course perspectives in order to answer these critical questions. We welcome both empirical (quantitative or qualitative) and theoretical papers. We particularly welcome papers that consider the challenges of merging historical and contemporary data in health and place research. Abstracts (maximum of 250 words) should be submitted to Niamh Shortt niamh.shortt@ed.ac.uk by September 30th 2016.